Any patient whose kidneys have
permanently stopped working is a potential candidate for a kidney
transplant. However, many factors must be considered in choosing between
transplantation and chronic dialysis for a given individual. Among these
factors are age, other medical problems, and personal considerations of
work and lifestyle. You should discuss the options with your doctor and
attempt to obtain as much information as possible in reaching your
decision.

There are three sources of
kidneys for transplantation: living related, living unrelated, and cadaver
donors. Living donors are usually members of the recipient’s immediate
family, such as siblings, parents or children. Only such close relatives
are likely to have an acceptable tissue match, although recent data
suggests that success with living unrelated kidneys is closer to that of
related grafts than that of cadavers. This may be due to better state of
the donor and less storage time. Cadaver donor kidneys are removed from
victims of brain death, usually the result of an accident or a stroke.

As the results seem better, and
the supply of cadaver kidneys remains low, living unrelated kidneys are
being considered increasingly. Spouses are the usual donors, although
rarely, friends can be used if extensively screened.

The success rate following
transplantation depends upon the closeness of the tissue match between
donor and recipient. A kidney from a brother or sister with a “complete”
match has a 95% chance of working at the end of one year. A kidney from a
parent, child, or “half-matched” sibling has an 85% chance of working for
at least one year. Finally, a cadaver donor kidney has an 80% change of
working at least one year.
All of these statistics assume
this is your first transplant, and that you will be taking the
anti-rejection drugs described elsewhere in this chapter. If you are having
a repeat transplant, the success rate will be 10%-15% less.
. These kidneys are not immortal,
however, with 50% of cadaver kidneys declining over 6 – 10 years, a rate
faster than the relatively stable success of related kidneys.

If the transplant fails,
patients return to dialysis as before. The transplant will be removed only
if it is causing symptoms, such as fever or pain. This is often necessary
if the kidney fails soon after transplant, but rarely if it fails after
several months. You may be able to have another transplant later, if you
desire.

One of the major achievements in
the field of transplantation in the last ten years has been a major
reduction in the risk of death. Currently at this hospital, the risk of
death in the first year after a kidney transplant is about 3 – 5%,
occurring primarily in high risk patients, particularly those over 60 – 65
and, to a less extent, those with juvenile diabetes. This includes death
from any cause, whether or not related to the transplant. This risk is not
significantly different from that sustained during a year of dialysis.
During your transplant evaluation, any risk factors you may have that will
increase your risk for transplantation will be identified and discussed
with you.

Advanced age is a significant
risk factor. Generally, patients over the age of 60 have done less well
than younger patients. Significant heart disease, particularly a history of
angina or prior heart attacks, will also increase the risk.
Because of the high incidence of
heart disease in diabetic patients, all diabetics must undergo an exercise
stress test before being accepted for transplantation. Chronic lung disease
increases the risk of pneumonia after transplantation.
Smoking will also increase this
risk, and all potential transplant patients are urged not to smoke.
Patients who are significantly overweight are more likely to have
complications in any surgical procedure, and should attempt to reduce
before transplantation. A history of other systemic diseases such as cancer
or hepatitis may also affect the risk; indeed, many patients with a history
of cancer or abnormal liver enzymes secondary to hepatitis may not be
accepted for transplantation. All of these factors vary in importance in
different individuals, and should be discussed with your doctor, as well as
with the transplant surgeon when you have your transplant evaluation.

It is rarely necessary to remove
your own kidneys prior to transplantation. This may be required if you have
severe high blood pressure uncontrollable by medication and dialysis, or if
your kidneys are chronically infected. However, whenever possible, your own
kidneys will be left alone. Even if not functioning normally, they continue
to make erythropoietin, a hormone your body requires to make red blood
cells, and they may make some urine. This is particularly important if your
transplant should fail.

The body has a normal defense
mechanism, called the immune system, which protects it from foreign
substances, such as bacteria and viruses. The body sees a kidney transplant
as foreign and attacks it to get rid of it. This process is called
rejection, and is a normal response of the body’s immune system. Even
though rejection may be prevented by medication, the possibility of
rejection never goes away. The body will not adapt to the kidney, nor will
the kidney change to accommodate the body, although after the first 3 – 6
months, rejection is less of a problem.

To prevent rejection patients
are given drugs, called immunosuppressive medications. These drugs work by
lowering the body’s immune response, making it incapable of destroying the
kidney. There are now several immunosuppressive medications available,
giving transplant physicians new flexibility in treating recipients. Most
patients will receive a combination of drugs. The newest of these
medications is called cyclosporine, a highly effective drug which has
considerably improved the results of transplants of all sorts.
Much of the early testing of
this drug was done at the Brigham and Women’s Hospital. Cyclosporine works
by interfering with the ability of your lymphocytes to cooperate normally
in attacking the transplant. It is now given in pill form in combination
with prednisone, a steroid medication with anti-inflammatory properties.
The combination of cyclosporine, Imuran (an older drug), and prednisone,
all in low doses, is used currently at the Brigham and Women’s Hospital for
all recipients of unrelated kidney transplants, and for all living related
donor transplants that are not perfectly matched.
The additional immunosuppressive
drug mentioned above is azathioprine or Imuran. Occasionally, patients are
switched from cyclosporine to Imuran several months after transplant to
avoid some potential side effects of long term cyclosporine administration.
Your doctor will advise you if this is necessary.

It will be necessary for you to
take some immunosuppressive medication for as long as you have the
transplant. Because the body never accepts the kidney as part of itself,
rejection can occur even years later, particularly if you stop your
medicines. However, it will be possible to reduce the dosage of medications
gradually over time, as the risk of rejection lessens with time.

All currently available
immunosuppressive medications have side effects. Some of these are common
to all such drugs, and some are particular for the individual drug. The
most important side effect these drugs have in common is that by reducing
the body’s immune defenses, they may actually increase the risk of
infection. Because they depress the body’s immune system in a non-specific
way, the body is less able to fight off some kinds of infection. This does
not mean that you will be ill frequently, but rather that there are some
kinds of infection only contracted by patients taking these or similar
drugs. Most of these infections are treatable, if detected early enough.
Therefore, it is very important that you report any symptoms such as fever
or a cough to your doctor without delay. Despite the risk, these infections
are not common; only about 15% of transplant recipients ever have any
significant infection.
Cyclosporine has a number of
special side effects, of which the most important is kidney toxicity.
Sometimes cyclosporine will cause your creatinine to rise, even in the
absence of any other problem. Usually this improves with a reduction in the
dose. Serial cyclosporine blood levels are currently available to help
decide the best dose for an individual patient. Other side effects rarely
caused by cyclosporine include mild hand tremors, hair growth, and
inflammation of the gums. These generally improve if the dose is lowered.
Side effects secondary to
prednisone occur much less commonly now than they did years ago, because so
much lower doses are used. The most common side effect now rarely seen is a
tendency to gain weight and develop a fat face. Other possible effects
include fluid retention, stomach irritation or ulceration, thinning of the
hair, acne, mood swings, bone disease, and delayed wound healing. Sugar
control will be more difficult for diabetics, and an occasional borderline
diabetic may require insulin for the first time. Many of these side effects
improve as the prednisone dose is lowered over the first year and, in
general, are infrequently seen..

Considerable research is being
done across the country to improve the immunosuppressive medications
available. Much of that work has been and continues to be done at Brigham
and Women’s Hospital. When you receive a transplant, you may be asked to
help in a research project. Complete information will be furnished before
any research is undertaken, and you will be under no obligation to
participate.

Tissue typing is a series of
laboratory blood tests which compare the genetic makeup, the natural
differences and similarities between the recipient and donor. These tests
cannot compare all genetic differences, but look at those which have been
found to be important for the success of a transplant.
HLA (human lymphocyte antigen)
typing examines a set of six antigens, three of which are inherited from
each parent. Four of these are the A and B antigens which have been known
for a long time; two are the Dr (region) antigens which have been more
recently discovered. Cadaver donor kidneys may be matched for from 0 to 6
of these antigens. Living related donor kidneys are generally matched for
three or six of these antigens, because they are inherited in groups of
three. Individuals are classified as high or low responders.

Tissue typing enables your
doctor to determine if a relative is an appropriate kidney donor. The tests
also help to predict the outcome of a transplant. Tissue typing is also
used to determine who would be the best recipient when a cadaver donor
organ becomes available, particularly if there is a six antigen matched
donor available.

General anesthesia is most
frequently used for kidney transplantation, although occasionally a spinal
or epidural technique may be recommended by the anesthesiologist.
Antibiotics are given to prevent infection, and a catheter is placed in
your bladder after anesthesia has been given. The transplanted kidney is
placed in the pelvis just above the pelvic bone, on either the right or the
left side. The kidney’s artery and vein are sewn your iliac artery and vein,
which are the large blood vessels leading to your leg. The ureter is
connected directly to the bladder. This technique is illustrated in the
drawing on this page. The operation normally takes about three hours.

The kidney transplant operation
itself is quite safe. Over 1,500 kidney transplants have been performed at
Brigham and Women’s Hospital, the technique is well established, and
technical complications are rare. Nevertheless, as with any operation,
difficulties may arise.
During the operation, you may
require a blood transfusion, particularly if you are already anemic. After
surgery, the most common complication is a urine leak, occurring about 5%
of the time. This may occur because of damage to the ureter during
harvesting of the donor kidney that was not recognizable at the time of the
transplant. The problem is almost always correctable, but may require a
second operation. Wound infections are very uncommon, thanks to modern
antibiotics.

Most patients will remain in the
hospital for one to two weeks following transplantation. Recovery from the
surgery itself is generally rapid. Patients are encouraged to be out of bed
on the day following surgery, and many are eating solid food within two or
three days. However, the possibility that the kidney may not work right
away, and the risk of rejection, may prolong your hospitalization.

Most patients return to work
after six to eight weeks. This will vary with each individual, depending
upon your response to the transplant, any complications which develop, the
type of work you do, and most importantly, how you feel. Because close
follow up is particularly important during the first three months after
transplantation, you should plan on frequent visits to the transplant
clinic and your own physician during this period.
However, transplantation is
intended to return you to as normal a lifestyle as is possible, and you
will be encouraged to return to your usual activities as soon as you are
able.

After a successful transplant
you will have a wider variety of food choices and will no longer need to
restrict fluids, protein, or phosphorus. However, you may need to restrict
sodium if you have high blood pressure. You may also need to limit
potassium, as some patients have high potassium levels while taking
cyclosporine. A feeling of well being and increased appetite may follow
transplant and cause you to gain weight, and you may need to watch your
calories.

About half of cadaver donor
kidney transplants do not make urine right away. During the process of
removing the kidney, storing it as long as one or two days, and placing it
in the recipient, some damage may occur. This damage is called acute
tubular necrosis (ATN), and is almost always reversible. It may be one to
three or more weeks before the kidney begins to make urine. During this
time you will require dialysis. ATN can also occur after living related
donor transplantation, but it is much less common.

Sometimes your body may make an
extra effort to reject the kidney despite the immunosuppressive
medications. This is referred to as a rejection episode. The symptoms and
signs of such an episode may be decreased urine output, fever, tenderness
over the kidney, high blood pressure, and a rise in creatinine, although
not all of these will necessarily be present. Sometimes a biopsy of the
kidney is required to make the diagnosis. This is done with a needle under
ultrasound guidance and is a minor and non-painful procedure.
When a rejection episode occurs,
an addition to your immunosuppression is required. Normally, this is a
steroid pulse, three daily intravenous injections of high doses of a
steroid drug called Solu-medrol. Administration of a pulse requires
hospitalization. Rejection episodes can also be treated with monoclonal
antibodies, which are designed to destroy the cells which trigger
rejection. The transplant team will discuss these options with you. Many
rejection episodes can be successfully reversed, but not all. Limitations
on the amount of treatment for rejection are observed in order to prevent
complications of overimmunosuppression. No more than three pulses are given
in the first six months after transplantation.

Almost all cadaver donor organs
in the six New England states are distributed through the New England Organ
Bank, an independent organization that serves the transplantation centers
in the region. These centers have agreed on an objective set of rules to d
etermine who gets a particular organ. When a donor becomes available,
tissue typing is performed to determine the characteristics of the donor. A
computer then compares this information with a list of the available
recipients to determine the best match.
The place of a patient on the
list depends on the length of time waiting; those waiting longest are on
the top. In addition, if a 6-antigen match becomes available anywhere in
the country, this will go to the most appropriate local matched donor.
Other factors determining the average waiting time for a kidney include the
number of donors, red blood cell type of the recipient, and the level of
sensitization.

Your body is capable of making
antibodies against other people’s HLA antigens. These antibodies may arise
because of blood transfusions, prior transplants, pregnancy, or for unknown
reasons. The more people against whom you have antibodies, the more highly
sensitized you are.
Sensitization levels are
measured by reacting a sample of your serum with a panel of lymphocytes
from many people. The results are expressed as the percent of the panel to
which you react, and are sometimes called PRA’s (panel reactive activity).
It may be difficult to find a kidney for you if you are highly sensitized,
because you cannot receive an organ from a person against whom you have
antibodies. Such a graft would be rejected immediately. To prevent this
possibility, patients waiting for cadaver organs are requested to send a
monthly serum sample to the tissue typing laboratory. These samples are
screened for antibody levels and stored. If the computer assigns a kidney
to you, these serum samples will be tested directly against the prospective
donor. This final test for antibody against the donor is called a
crossmatch.

A number of factors enter into
this decision, including success rates following transplantation and the
availability of donors. The best results following transplantation are
obtained with HLA-identical (6 antigen matched) living related donors,
which almost always come from a sibling, rarely from a cadaver. As noted
before, the available results on living unrelated donor kidneys show them
to be better than those for cadavers.
A major advantage of living
donor transplants is the ready availability of the donor. This allows the
transplant to be performed without a long waiting period, as there are
currently more potential recipients than available cadaver donors. For this
reason, we encourage living related donation whenever the family situation
is appropriate, and, if circumstances are correct, donations for spouses.

Potential living related donors
usually are identified in discussions with your family and your doctor.
Tissue typing is then scheduled; the required tests include blood group
typing, HLA typing, and a mixed lymphocyte culture. Based on these tests it
is frequently possible to identify the donor most likely to result in a
successful transplant. Choosing the donor is best done in consultation with
your doctor and the transplant team.
The selected donor is then
scheduled for admission to the hospital for a donor evaluation. This
evaluation is primarily on an out-patient basis and involves a wide variety
of tests to ensure the health of the donor. Included in these tests is an
arteriogram, an x-ray procedure in which dye is injected into the arteries
supplying the kidney. This test allows the surgeon to decide which kidney
would be best to remove. After completion of all tests, the physician
responsible for the donor evaluation, who is not a member of the transplant
team, will discuss the results with the potential donor privately. Only
donors who are healthy and have two completely normal kidneys will be
accepted.

The short term risks of donation
are those associated with major surgery, including the risks of general
anesthesia, wound infection, and the possible need for a blood transfusion.
These risks are very small in healthy people. The donor evaluation process
is designed to identify any special factors which would place a donor at
increased risk; such donors would not be accepted. The longer term risks
are slightly more uncertain. Some studies of donors 10 – 15 years following
donation have suggested a slightly higher incidence of mild high blood
pressure and protein in the urine; although these changes are not
particularly different from the general aging population.
The significance of these
studies is unknown, and there is no evidence of renal failure in prior
donors. The remaining kidney expands and takes over the function previously
performed by two. Because most kidney diseases affect both kidneys
simultaneously, the donor is not at increased risk of kidney failure should
he or she contract such a disease. Donors are cautioned to avoid contact
sports or other activities which could cause major trauma to the remaining
kidney. We believe that donors will lead perfectly normal lives. It is fair
to state, however, that possible consequences of donation after more than
twenty years are unknown, primarily because transplantation of kidneys in
significant numbers only began about twenty years ago.

Medicare and/or your private
insurance will cover the expenses of your kidney transplant. After the
transplant, Medicare will pay for 80% of your out-patient clinic visits.
Your Medicare will terminate 36 months after your transplant, unless you
have restarted dialysis before that date. In addition, Medicare pays for
80% of the cost of FDA-approved immunosuppressive medications for one year
following hospital discharge after the transplant. No one will be denied
the best possible medical care because of his or her financial
circumstances. The transplant social worker is available to assist with any
financial or insurance concerns.

Inform your physician of your
interest and ask him to arrange a referral for transplant evaluation. This
can be arranged conveniently through our transplant coordinator. Prior to
your appointment, the following information should be sent to us:

During your evaluation you will
meet with one of the transplant surgeons, a transplant nurse, a social
worker, and the transplant coordinator. Your medical condition will be
reviewed and further information about transplantation will be provided.
Tissue typing is frequently performed during this visit. A tour of the
transplant unit can be arranged if you desire. You are encouraged to ask as
many questions and to spend as much time with us as you like. We believe it
is very important for you and your family to be as well informed about
transplantation as is possible.
After your evaluation, a letter
will be sent to your physician informing him of the results and requesting
any further information needed. If you are to receive a living donor
transplant, arrangements for both the donor evaluation and the transplant
will be completed by the transplant coordinator. If you are to receive a
cadaver donor transplant, your name will be listed with the New England
Organ Bank. You will be required to send one red top tube of blood to the
tissue typing laboratory each month for sensitivity screening; instructions
for this will be furnished during your transplant evaluation.

Normally, you will not be
informed of the possible availability of a cadaver kidney until it has been
assigned to you. Occasionally, you may need to be told before the final
crossmatch has been completed, particularly if the kidney has already been
stored for a prolonged length of time. Normally, a cadaver donor kidney can
be safely stored for 48 hours. About 12-18 hours are required for tissue
typing, leaving 30-36 hours to make arrangements for and to perform the
transplant.
Once the kidney has definitely
been assigned, you should not have anything further to eat or drink. If you
are a diabetic, be sure to discuss this with the physician who notifies you
of the transplant. You may need to be dialyzed before the transplant, dep
ending upon when you were last dialyzed, your blood chemistries, and your
general medical status. This dialysis will be arranged at either your own
unit or here, depending on the dialysis schedule and the timing of the
operation. You should make arrangements to travel to the hospital as
quickly as possible. However, extreme speed is not required, so please
drive normally and safely. It would be preferable to have someone else
drive for you.

You will automatically be placed
on the transplant list as soon as all your tests are completed and the
tissue typing laboratory has received two monthly screening samples. You
will then remain on the list as long as monthly screening blood samples are
sent, until such time as you receive a transplant. If you develop medical
problems which require that you be temporarily removed from the list,
please be sure your doctor notifies us when you are able to be relisted.
Your position on the list will not be affected by temporary inactivation.
If you have any questions about your current status, please contact the
transplant coordinator.